Open Carpal Tunnel Release

Craig M. Rodner and Julia Katarincic

Summary: Open release of the transverse carpal ligament (TCL) has been the gold
standard surgical treatment for patients with carpal tunnel syndrome over the past 50
years. Transecting the TCL with a scalpel under direct vision produces reliable
symptom relief in the vast majority of cases. However, despite the clinical success of
this technique, transient post-operative pillar pain, scar tenderness, or weakness are
known to occur in some patients. Key Words: Carpal tunnel syndromeOpen carpal
tunnel release.
Carpal Tunnel Syndrome (CTS) is the most common
compression neuropathy of the upper extremity.
57
The
first described case of median neuropathy at the wrist, by
Sir James Paget in 1854, involved a patient who had a
rope tied tightly around his wrist and had such unrelent-
ing pain and parasthesias subsequently that he required
an amputation.
52
In 1913, Marie and Foix performed an
autopsy on a patient with bilateral thenar muscle atrophy
and found bilateral median neuromas just proximal to the
transverse carpal ligament (TCL).
43
Based on this patho-
logic finding, they were the first authors to suggest
therapeutic sectioning of the TCL to decompress the
median nerve. In 1938, the neurologist Moersch coined
the term carpal tunnel syndrome,
47
but it was not until
years later, with George Phalens monumental work in
the 1950s, 1960s, and 1970s, that CTS became a well
defined clinical entity.
5557
In his reviews of hundreds of
hands afflicted with a similar constellation of symptoms,
Phalen concluded that the median nerve is easily com-
pressed by any condition that increases the volume of the
structures within the carpal tunnel.
56
For the past 40
years, transecting the TCL under direct visualization (an
open carpal tunnel release) has been accepted as a reli-
able treatment for patients with CTS refractory to non-
operative measures.
This chapter will focus on the technique involved in
performing an open carpal tunnel release (OCTR). Any
such discussion must begin with a through understanding
of the pertinent anatomy of the surgical area.
ANATOMY
The carpal tunnel is a well-defined, inelastic channel
located in the volar wrist. It is oval in shape and extends
from the distal volar wrist crease to the mid-palm, just
proximal to the superficial palmar arch. The carpal tun-
nel is bordered ulnarly by the hook of the hamate,
triquetrum, and pisiform, radially by the trapezium,
scaphoid, and flexor carpi radialis retinaculum, dorsally
by the concave arch of the carpal bones and metacarpal
bases of the central rays, and anteriorly by the transverse
carpal ligament (TCL). The TCL measures 1 to 3 mm in
thickness throughout its length and is 3 to 4 cm wide.
Nine extrinsic flexor tendons pass through the carpal
tunnel (flexor digitorum profundus, flexor digitorum su-
perficialis, and the flexor pollicis longus), along with the
median nerve that typically lies volar and radial to the
tendons. The palmar cutaneous branch of the median
nerve (PCBMN) originates from the volar-radial portion
of the median nerve approximately 5 cm proximal to the
wrist crease. It travels with its parent nerve for a distance
of 2 cm, before branching off in between the flexor
carpai radialis and palmaris longus. One centimeter prox-
imal to the wrist crease the PCBMN penetrates the
antebrachial fascia into the subcutaneous layer to provide
sensation to the proximal radial palmar skin. At the distal
end of the carpal tunnel, the median nerve typically
From the Department of Orthopedic Surgery, Brown University/
Rhode Island Hospital, Providence, Rhode Island.
Address correspondence and reprint requests to Julia Katarincic,
Department of Orthopedic Surgery, Brown University/Rhode Island
Hospital, Providence, RI. E-mail: juliakatarincic@aol.com
Techniques in Orthopaedics

21(1):311 2006 Lippincott Williams & Wilkins, Inc.

3
divides into 6 branches: a motor nerve, three proper
digital nerves, and two common digital nerves. The
motor branch innervates the radial lumbricals and the
thenar intrinsic musculature (the opponens pollicis, the
abductor pollicis brevis, and superficial portion of the
flexor pollicis brevis). The variation in the anatomic path
of the motor branch of the median nerve is well docu-
mented.
37
Most of the time (4690%), the recurrent
motor nerve is extra-ligamentous and branches off
distal to the TCL. Less commonly, the motor nerve is
sub-ligamentous and branches off beneath the TCL,
travels in a distal direction, and then exits the carpal
tunnel distal to the TCL. The least common, but most
concerning, route for the motor branch to take has been
dubbed trans-ligamentous, describing a motor branch
which penetrates the TCL on its exit from the carpal
tunnel.
37
It is important to keep in mind that there are
other, less common, branching variations of the recurrent
motor nerve, such as coming off of the ulnar portion of
the parent nerve or exiting extra-ligamentously but
then, as it becomes recurrent, laying down on top of the
TCL before it travels radially into the thenar muscles.
Another less common variation of median nerve anat-
omy at the wrist is that the main nerve trunk may be
bifid, divided by an anamolous muscle or a persistent
median artery.
40
Sensory variations in median innerva-
tion are common, although typically it supplies sensation
to the radial three and a half fingers, mostly on the volar
surface of the hand. The presence of transverse commu-
nicating branches between the common digital nerves of
the third and fourth web spaces
16,45
may help explain the
variability between individuals in their sensory innerva-
tion of the small, ring, and middle fingers.
Bordered on all sides by either bone or thick ligament,
the carpal tunnel can truly be regarded as a closed
compartment with a normal internal milieu and pressure.
Any increase in the size of the structures within the
carpal tunnel or decrease in the volume of the carpal
tunnel may cause the internal pressure in this closed
compartment to exceed the tolerance of the median nerve
and lead to the symptoms of CTS. Although it is unclear
whether these symptoms are the direct result of mechan-
ical compression or relative ischemia of the median
nerve, there is no doubt that resting carpal tunnel pres-
sures are higher in patients with CTS (30 mm Hg) than
without (2.5 mm to 10 mm Hg).
21
Before deciding on which type of treatment is most
appropriate for a patient with hand pain and numbness, it
is first important to make a correct diagnosis through a
thorough history and physical examination.
DIAGNOSIS
An essential part of making the diagnosis of CTS is
taking a thorough history. Although one patient with
CTS may complain of throbbing pain as the chief com-
plaint, another may complain of nighttime tingling and
no pain at all. Whereas no one sign or symptom is unto
itself pathognomonic, the classic clinical presentation of
CTS includes pain and parasthesias in the median nerve
sensory distribution of the hand, often worse at nighttime
and exacerbated by activities which require a fixed po-
sition of the wrist. Patients may describe difficulty with
opening jars, holding a phone or hairbrush, driving a car,
or sleeping. Although sensory symptoms are most com-
mon, weakness may become more pronounced over
time.
It is important to recall that numbness and tingling in
the radial three fingers does not necessarily mean the
patient has a median neuropathy at the wrist. Such
symptoms can commonly result from cervical spondylo-
sis, disc protrusion, or both. Therefore, evaluation of any
patient with these symptoms must involve a complete
examination of the cervical spine and upper extremity to
rule-out a more proximal lesion (such as a C5-6 or C6-7
radiculopathy, brachial plexopathy of the upper trunk or
lateral cord, or a pronator syndrome). Although sensory
complaints are the hallmark of CTS, the incidence of
abnormal findings on an objective sensory examination
may be low. The sensory examination of the involved
hand may include both threshold tests (monofilament or
vibrometry) and innervation density tests (two-point dis-
crimination), with the former being more consistent and
reliable in diagnosing CTS than the latter. There are
several specific provocative tests which have been well
described to elicit the symptoms of CTS and suggest its
diagnosis, including Tinels sign,
66
Phalens sign,
56
and
the more recently described carpal tunnel compression
test, or Durkans sign.
18
A positive Tinels sign is de-
fined by a reproduction of symptoms with tapping over
the TCL and a positive Phalens sign is defined by a
reproduction of symptoms with maximal flexion of the
patients wrist for 60 seconds. A positive Durkans sign
is reproduction of symptoms with direct pressure of the
volar wrist. None of these provocative tests are requisites
for making the diagnosis of CTS, as their sensitivities
and specificties have varied widely in the litera-
ture.
24,35,56,71
Abnormalities in the motor examination are
rare and usually occur only after significant sensory loss.
Weakness of the abductor pollicis brevis (APB) is the
most sensitive motor sign for CTS. Thenar atrophy is a
rare finding and may be present in severe, chronic cases
of CTS.
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Electrodiagnostic testing is commonly performed in
the evaluation of CTS and includes both nerve conduc-
tion velocity (NCV) and electromyography (EMG). Nor-
mal NCV values vary, but are generally thought to be a
distal motor latency of less than 4.5 msec and a distal
sensory latency of less than 3.5 msec.
65
EMG of the
thenar intrinsic musculature can be used to evaluate the
severity or chronicity of median nerve dysfunction. It is
important to note that while electrodiagnostic testing
represents an important diagnostic tool, negative results
do not absolutely exclude the diagnosis of CTS.
26
NONOPERATIVE TREATMENT
Once the diagnosis is made, nonsurgical therapies are
usually tried first in cases of mild and moderate CTS.
Such measures are aimed at alleviating mechanical com-
pression of the median nerve at the level of the wrist and
treating any contributing underlying causes. Nighttime
wrist splinting in the neutral position is the mainstay of
conservative treatment as neutral positioning of the wrist
has been shown to minimize intra-tunnel pressures.
32,70
Oral medications, such as nonsteroidal anti-inflammato-
ries (NSAIDs), diuretics, and vitamin B6
5
may play a
role in the nonoperative management of CTS, although
they have never been rigorously studied in the literature.
Steroid medication is sometimes used in the treatment of
CTS and has been shown to reduce hallmark symptoms
versus placebo both when taken orally
9
and when in-
jected directly into the carpal tunnel,
15,20
although their
benefits appear more short-term than those of surgical
TCL release. There are several other nonsurgical modal-
ities proposed for treating mild CTS, such as ultrasound,
iontophoresis, and various exercises (such as tendon and
nerve gliding and even yoga).
OPEN CARPAL TUNNEL RELEASE
Surgical management of patients with CTS is indi-
cated if symptoms persist despite nonoperative treat-
ment. It may also be indicated in patients who present
initially with advanced findings, such as constant finger
numbness, thenar weakness or atrophy, or with electro-
diagnostic evidence of thenar denervation. As demon-
strated by the breadth of chapters in this publication,
there have been several different approaches to decom-
pressing the carpal tunnel over the years, from OCTR, to
more limited-open approaches using commercially avail-
able products, to endoscopic techniques. Described by
Sir James Learmonth in 1933,
38
OCTR has become the
gold standard surgical treatment for patients with CTS. It
has produced uniformly excellent results with high pa-
tient satisfaction and a low complication rate.
23
Some
investigators, however, have suggested that OCTR is
associated with a high enough incidence of postoperative
palmar discomfort, scar tenderness, and weakness that
endoscopic release should be considered as a viable
alternative.
2,3,10,11,46,50,53,59,61
No matter the operative
method, transecting the TCL is the essential step in each
of them to increase the volume and decrease the pressure
around the median nerve in the carpal tunnel. Indeed,
magnetic resonance images (MRI) studies
1,60
have
shown that transecting the TCL causes a 24% increase in
the volume of the carpal tunnel, as it changes from an
oval to more circular cross-section, and shifts the median
nerve anteriorly by 3.5 mm. Although several different
methods have been successfully used to achieve this end,
transecting the TCL with a scalpel under direct visual-
ization (OCTR) remains the mainstay of surgical man-
agement.
TECHNIQUE
OCTR affords the surgeon full inspection of the TCL,
the possible presence of an intra-ligamentous motor
nerve branch to the thenar muscles, and the contents of
the carpal tunnel. The length of the incision that is made
during an OCTR depends on both patient and surgeon
factors. Traditionally, OCTR was done through a rela-
tively large 4 to 5 cm longitudinal incision extending
from Kaplans cardinal line distally to beyond the wrist
crease proximally. Over time, this incision has been
minimized in general, and most hand surgeons today
perform primary OCTRs through a 2 to 4 cm incision,
which ends approximately 2 cm distal to the wrist crease.
Regardless of the length of incision, each OCTR should
proceed through the same reproducible steps: 1) Set-up;
2) skin incision; 3) Palmar fascial incision; 4) TCL
release; and 5) postoperative care. We shall discuss each
of these in turn.
Set-Up
The patient is brought to the operating room and a
tourniquet is placed on his or her forearm to minimize
intra-operative bleeding. Anesthesia choice is surgeon
dependent and local, regional, or general anesthesia may
all be used. We prefer local analgesia with conscious
sedation. After administration of conscious sedation
(commonly a mixture of versed and propofol), we infili-
trate the carpal tunnel and surrounding subcutaneous
tissue with a mixture of 10 ml of bupivicaine and
lidocaine.
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Skin Incision
After washing and draping the extremity, a longitudi-
nal incision placed along the axis of the radial border of
the ring finger, approximately 2 mm ulnar to the thenar
crease, is generally regarded as the safest location for an
OCTR incision. Most hand surgeons avoid transverse
palmar incisions
7
because of inadequate exposure and
potential injury to the palmar cutaneous nerve branch of
the median nerve. The standard longitudinal incision
begins distally at Kaplans cardinal line (which is a line
drawn obliquely from the apex of the inter-digital fold
between the thumb and index finger distally, toward the
ulnar side of the palm parallel to the proximal palmar
crease, and passing 45 mm distal to the pisiform) and is
extended 2 to 4 cm proximally toward the wrist crease
(Fig. 1). Extending the incision proximal to the wrist
crease is generally not required in a primary OCTR.
When planning this incision, care should be taken to stay
radial to the hook of the hamate. This may help avoid the
occurrence of palmar scar over the hamate hook, as well
as minimize injury to the ulnar neurovascular bundle.
Making sure that the incision does not project signifi-
cantly more radially than the inter-thenar depression is
important in avoiding injury to the palmar cutaneous
branch of the median nerve (PCBMN).
68
However, ulnar
cutaneous nerves reside in this very region and it is
important to recognize, particularly in dealing with post-
operative cases of peri-incisional pillar pain, that there
is no true inter-nervous sensory plane in the palm.
4,7,44
It
is important to note that if the PCBMN is cut during the
procedure, it is preferable to dissect it proximally and
section it at its origin from the median nerve rather than
to repair it; as repair usually results in a bothersome
neuroma.
Palmar Fascial Incision
After the skin is incised longitudinally, two retractors
are placed perpendicular to the incision, exposing a layer
of subcutaneous fat. A ragnell retractor is then placed
parallel to the incision at its proximal margin and sweeps
this layer of fat proximally, exposing the longitudinally
oriented fibers of the palmar fascia. Under direct visual-
ization, a scalpel is used to incise in the midline of the
palmar fascia fibers. It is important to incise the palmar
fascia the full length of the skin incision so as to
maximize visualization of the deeper structures. After
picking up each edge of the incised palmar fascia with
forceps, the 2 retractors are then placed deep to the
fascial edges and, by retracting perpendicular to the
incision, the transverse fibers of the TCL are revealed. It
is important to note that this approach is in close prox-
imity to the ulnar tunnel at the wrist (Guyons canal) and,
with more superficial dissection ulnar to the hamate, the
ulnar nerve may be decompressed if its release is indi-
cated.
62
TCL Release
With the longitudinal fibers of the palmar fascia being
pulled perpendicular to the incision, the transverse fibers
of the TCL should be clearly visualized. If these fibers
are obscured in any way, better visualization must be
obtained before moving on to transecting the ligament.
Using a sponge to clean off any fascial remnants from
these fibers can be helpful. Sometimes a palmaris brevis
muscle belly may be present at this level, lying between
the palmar fascia and the TCL. It is helpful to note that
whenever a palmaris brevis is encountered, the TCL is
found deep to it and can be exposed by sharply elevating
the palmaris brevis muscle fibers off of the TCL, often in
FIG. 1. The standard longitudinal incision for an OCTR is in line
with the radial border of the ring finger, beginning distally at Kaplans
cardinal line and extending 2 to 4 cm proximally toward the wrist
crease.
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a radial-ward direction. Directly visualizing the TCL
must be achieved before transecting it during an OCTR,
so as not to injure an intra-ligamentous motor branch
of the median nerve. Once visualized, the TCL is divided
longitudinally along its ulnar aspect from distal to prox-
imal. A ragnell retractor is placed proximally and then
distally at the apices of the incision to facilitate exposure
of the proximal and distal margins of the TCL as it is
being transected (Fig. 2). Staying near the TCLs ulnar
attachment keeps the plane of ligament transection, ex-
cept for anamolous cases, safely away from the recurrent
motor branch of the median nerve. Although the ulnar
neurovascular bundle typically resides ulnar to the
hamate hook in Guyons canal, the surgeon must be
aware that it can be located radial to the hook in some
instances. The distal end of the TCL is marked by the bed
of adipose tissue surrounding the superficial palmar
arterial arch. Proximally, the TCL is incised under direct
visualization to the level of its confluence with the
antebrachial fascia at the wrist crease. If the antebrachial
fascia appears to be particularly thickened, which may be
the case in patients with connective tissue disease, it may
be helpful to release this tissue.
31
Minimizing superficial
proximal dissection may decrease postoperative forearm
pain.
After complete release of the TCL, attention is next
turned to the course of the motor branch of the median
nerve. If a trans-ligamentous route is observed, care
should be taken to completely free this branch through
further dissection of the ligament. Once the TCL is
sectioned, and the motor branch identified, the contents
of the carpal tunnel are grossly inspected. The median
nerve is typically located volar and radial to the nine
extrinsic flexor tendons within the canal and its appear-
ance should be noted by the surgeon. Although there are
frequently cases in which the nerve appears quite normal,
other times it can have a bluish-red discoloration proxi-
mal to the area of compression and/or an edematous
hour-glass morphology, representing a neuroma-in-
continuity.
49
Adjunctive procedures to structures within
the carpal tunnel, such as internal median neurolysis or
flexor tenosynovectomy, are rarely indicated. Although
initially favored by some surgeons to address intra-
neural fibrosis in cases of severe CTS,
13
performing a
routine median neurolysis or epineurotomy during
OCTR has repeatedly been shown to offer no advantage
over control groups.
6,19,22,27,39,41
Similarly, routine flexor
tenosynovectomy during OCTR is not advised, as it has
been shown to offer no benefit compared with transect-
ing the TCL alone in treating idiopathic CTS.
64
How-
ever, there may be a role for tenosynovectomy in patients
with concominant connective tissue disease and accom-
panying flexor tenosynovitis.
After the TCL is transected along its ulnar border and
the median nerve completely decompressed from the
distal forearm fascia to the superficial palmar arch, the
wound is irrigated and hemostasis achieved. Our inci-
sions are closed with interrupted mattress sutures (4-0 or
5-0 nonabsorbable material) and covered with a soft
dressing and compressive wrap, with careful attention
paid to not restrict any digital movement (Fig. 3).
Postoperative Care
Immediately after the surgery the patient is encour-
aged to move his or her fingers freely. Light hand use
and active digital motion is encouraged during the next 7
to 10 days, until the patient returns to the office for a
wound check and suture removal. In our experience,
resumption of full activities of daily living and return to
work usually occurs within 2 to 6 weeks. Formal reha-
bilitation programs are not usually necessary. Although
there is no evidence to support the use of postoperative
splints, some surgeons use them transiently to prevent
concominant wrist and finger flexion that could theoret-
ically sublux the flexor tendons out of the canal. Patients
experiencing postoperative pillar pain have signifi-
cantly more difficulty returning to work than the major-
ity of patients after OCTR. Pillar pain is best defined
as pain in the thenar or hypothenar areas and may be due
to a variety of factors: scar sensitivity, neuromas of
cutaneous nerve endings, changes in carpal arch dynam-
ics or thenar and hypothenar muscle origins, and/or
decreased median nerve gliding. Such patients may ben-
efit from receiving hand therapy (for tendon and nerve
gliding) and therapeutic modalities to try to decrease
peri-incisional inflammation.
FIG. 2. With the longitudinal fibers of the palmar fascia incised and
retracted, the TCL is well visualized and divided longitudinally along
its ulnar aspect.
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ALTERNATIVE OPEN TECHNIQUES
While most authors suggest transecting the TCL along
its ulnar portion, a radial incision has also been described
and deserves mention.
69
Weber and Sanders describe an
incision made over the flexor carpi radialis tendon,
proximal to the wrist crease. The tendon is then used as
a guide to follow distally and dissect the TCL off of its
radial insertion. Although not a mainstream approach,
this method may be associated with less pillar pain
than more traditional incisions and may have a role in
patients who have CTS and a concominant distal radius
fracture undergoing open reduction and internal fixation
via a volar approach.
Another alternative technique for OCTR actually in-
volves preserving the TCL, which has been suggested to
maximize postoperative grip strength. By performing a
step-cut lengthening of the ligament
30
or reconstructing it
with a transposition flap or with palmar fascia,
48
the TCL
can be maintained and its theoretically important flexor
tendon pulley function preserved. In this way, some
authors have suggested that preserving the TCL in a
lengthened capacity alleviates CTS symptoms while
maximizing postoperative grip strength.
OUTCOMES AND COMPLICATIONS
OCTR has been the mainstay of surgical treatment for
CTS over the past several decades and has been shown to
produce reliable alleviation of patient symptoms (rang-
ing from 8198%) with minimal complica-
tions.
8,23,29,33,51,5557
However, there is a group of pa-
tients in which there is no period at all after surgery that
there is an improvement in preoperative symptoms. Al-
though this may be due to a variety of reasons, it
classically suggests the possibility of an incomplete re-
lease of the TCL. Incomplete release is associated with
because of inadequate visualization and has been sug-
gested to occur more frequently with both transverse and
so-called mini incisions. Several authors cite the distal
retinaculum as the most common site of incomplete
release in open surgery.
12,36
A second reason patients
may have a persistence of symptoms after surgery is that
they did not actually have CTS in the first place, but
rather a more proximal nerve lesion as might be the case
with a cervical radiculopathy, brachial plexopathy, or a
pronator syndrome. Thirdly, a median neuropathy at the
wrist may have in fact been present and fully decom-
pressed, but an occult proximal lesion could explain
persistent symptoms by producing a double crush
phenomenon. Fourth, symptoms may persist when there
is an intrinsic neuropathy present, as in advanced cases
of CTS with preoperative evidence of thenar dennerva-
tion or in patients with systemic polyneurpathy, such as
patients with diabetes. Fifthly, persistent symptoms may
be because of untreated space-occupying lesions in the
carpal tunnel, such as a ganglion, other tumor, displaced
lunate, inflamed flexor tenosynovium, or a gouty to-
phus. In these rare circumstances, releasing the TCL is
helpful, but may not be sufficient to fully decompress
the median nerve. Finally, because of anatomic vari-
ation, perineural scar, or surgical error, the median
nerve may be iatrogenically injured during the opera-
tion, leading to continued symptoms despite surgical
release. Although OCTR is a safe, theoretically simple
procedure, its potential complications are indeed well
documented.
54
In their review of questionnaires sent to members of
the American Society for Surgery of the Hand, Palmer et
al. gathered data regarding major complications, after
FIG. 3. After the incision is closed, the hand is covered with a soft
dressing and compressive wrap, with careful attention paid to not
restrict any digital movement.
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both endoscopic and open CTR, that had been surgically
treated by hand surgeons over a 5-year period.
54
Al-
though Palmer et al. acknowledge the inherent limita-
tions of a retrospective voluntary study, the data are
nonetheless provocative and underscore the fact that this
surgery is not without substantial potential risk. There
were 283 major complications after OCTR treated by
616 respondents. These complications included 147 me-
dian nerve lacerations (23 complete), 29 ulnar nerve
lacerations (11 complete), 54 digital nerve lacerations,
34 vessel lacerations (21 superficial palmar arch), and 19
tendon lacerations (13 complete). The incidence of
infection after OCTR is generally thought to be less
than 1%, with Staphylococcus and Streptococcus the
most common affecting organisms. Most infections
are cellulitic in nature and can be treated with oral or
parenteral antibiotics, although sometimes incision
and drainage can be necessary. Postoperative skin and
palmar fascia necrosis is an uncommon, but reported,
complication of OCTR and, as with any case of
necrotizing fasciitis, should be managed surgically
and aggressively.
25
It is important to note that, even if the OCTR proce-
dure is performed technically perfectly and even if all
preoperative symptoms are relieved, there is a significant
group of patients who have postoperative complaints,
because of lingering discomfort at the base of the palm in
the thenar or hypothenar area (so-called pillar pain),
scar tenderness, or weakness.
14,33,34,63
The etiology of
postoperative pillar pain remains controversial. If its
cause is because of alterations in the carpal arch or in the
origin of the hypothenar and thenar musculature that
occur after transection of the TCL, one would expect
pillar pain in both endoscopic and open surgery, re-
gardless of the size of the incision.
28,67
An alternate
theory is that violating the palmar skin, cutaneous
nerves, and underlying palmar fascia is responsible for
this phenomenon; a theory advocated by proponents of
endoscopic and mini-open techniques.
42
Despite its prev-
alence, postoperative pillar pain remains a perplexing
problem that has no reliable treatment other than the
tincture of time. Povlsen et al. have indeed shown that
pain over the thenar and hypothenar eminences improves
with time, with 41% of the patients they reviewed expe-
riencing such pain one month postoperatively, but only
6% had this pain 1 year after surgery.
58
Partly because of
dissatisfaction with the relatively high incidence of post-
operative pillar pain and scar tenderness in their pa-
tients, many surgeons embraced endoscopy as an attrac-
tive alternative to OCTR when instrumentation became
commercially available in 1990.
2,3,10,11,46,50,53,59,61
This
technique will be discussed at length elsewhere in this
publication.
CONCLUSION
Open release of the TCL has been the mainstay of
surgical treatment for CTS for the past several decades,
producing reliable symptom relief in the vast majority of
patients. The nerve is directly visualized so chance of
injury should be rare. It is important to note that, even
with the most diligent surgical technique, transient post-
operative pillar pain, scar tenderness, or weakness
commonly occur. Using this technique, patients can
reliably have good relief of their carpal tunnel symptoms
and most return to the majority of activities in about 6
weeks.
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